Thanks to Dr. John Principe and Dr. Dan Girzadas for hosting the January 2015 Journal Club at Dr. Principe’s WellBeingMD Center.  Appropriately, the topic was wellness, and the delicious and nutritious dinner prepared by the Center’s chef and staff was enjoyed by all.  Outstanding presentations by Drs. Parker, Cirone, Burt, Bamman, Negro and Nejak, as well as the Usastrana demo by Dr. Negro-Namaste.

 

1.     Shanafelt TD, et al: Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the 
General US Population.  Arch Intern Med 2012;172:1377-1385.   

 

Burnout, including loss of enthusiasm, cynicism, and low sense of accomplishment, has negative professional and personal consequences.  This survey of US physicians from all medical specialties attempted to evaluate rates of burnout and satisfaction with work-life balance.  Of 27,276 physicians invited to participate, 7288 completed the surveys.  Using the Maslach Burnout Inventory, 46% of all physicians reported at least one symptom of burnout, with Emergency Medicine at the top of the list (>60% of EM physicians), followed by Family Medicine and Internal Medicine.  Compared with a sample of US working adults, physicians were more likely to have symptoms of burnout and be dissatisfied with work/life balance.  Limitations:  there was only a 27% overall response rate, and only 333 emergency physicians.  One always has to question motivation of survey respondents, and wonder about the large group who did not respond.

 

So, how do we avoid/mitigate burnout?  Talk to Cirone, he has it all worked out.  Other voices in the room suggested:  Develop a niche-do something professionally beyond just working your shifts.  Nurture your other passions, outside interests, and relationships.  Retain your sense of humanity; wonder at the amazing intimacy our patients, true strangers, allow us.  You’ll forget more medicine than your patients will ever know-give them a break.  Teach students and residents:  medical, nursing, paramedic.  I didn’t see the movie, but Sam Lam alluded to “Frozen”, and the importance of being pushed to capacity and a little beyond our comfort zone.  Finally, maybe at some point, for some, burnout isn’t bad, but a message that it’s ok to leave, and pursue other interests.

 

2.     Hall KN, et al:  Factors Associated with Career Longevity in Residency-Trained Emergency Physicians.  Ann Emerg Med 1992;21:291-297.  

 

This 23-year-old retrospective cohort study of EM residency graduates from 1978-1982 used a mailed (what’s the internet?) questionnaire to identify factors associated with leaving the specialty.  There were 539 responses for a 63% response rate.  Factors associated with remaining in emergency medicine were board certification, working with residents during their EM practice, as well as having an income of more than 100K/year.   Ten-year professional survival rate was 85%.  EM physicians who had left the field were more likely to be board certified in another specialty, and less satisfied with EM as their initial choice of specialty.

A reminder of how far we’ve come.  Less than 40 years ago, during these 4 early years of our specialty, there were a total of only 858 EM residency graduates.  Significant numbers of EM physicians were board certified in another specialty.  It’s difficult to know the reasons those early emergency physicians chose training in EM, and there was no such thing as a medical school rotation in EM.  As of 2014, there were 170 emergency medicine programs, with 1,786 EM residency positions offered in the match.   We have 27 types of EM fellowship training, with EM residency groups and faculty advisors to help guide medical students in their choice of career.   An EM physician will become president of the AMA in June of 2015.

 

The first sentence of the article’s discussion is telling:  “Previous reports have questioned the ability of emergency medicine to survive as a specialty due to the amount of stress this type of practice generates.”  While no one would deny the stress of our jobs, our specialty has grown and thrived.  It would be hard to extrapolate findings from this study to today’s population of emergency physicians.

 

 

3.     Wang X, et al:  Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies.  BMJ  2014;349:g4490.   

 

“Eat Food, Not Too Much, Mostly Plants.”  

–Michael Pollan, author of The Omnivore’s Dilemma and In Defense of Food, among others

 

In this stunning meta-analysis of 16 articles including >800,000 subjects and 4.6-26 year followup, it was revealed that your mother is right-eat your fruits and vegetables.  Each additional daily serving of fruits or vegetables was associated with a decrease in all cause and CV mortality.  No change in cancer mortality-perhaps because cancer is so heterogenous in origin depending on organ, with potential for substantial genetic predisposition?  Limitations include the self-report nature of surveys and poor adjustment for other dietary factors.  Not a strong article; as Harwood mentioned, we might not be nodding in agreement so readily if it was advocating cobra venom rather than something so aligned with our common sense....but hey, go eat a rambutan.

 

If you’d rather not read the meta-analysis, suggest reading something by Michael Pollan (http://michaelpollan.com/books/).

 

4.     Cramer, H, et al: Effects of yoga on cardiovascular disease risk factors: a systematic review and meta-analysis.  Int J Cardiol  2014 May 1;173(2):170-83. 

 

Finally, an article after my own heart chakra.  A systematic review of 44 RCTs with >3,000 patients, evaluating the effects of yoga on modifiable cardiovascular risk factors.  Small improvements in BP, HR, RR, waist circumference, cholesterol and HbA1c were noted.  Not sure if any of these differences would be considered clinically relevant, and there was high or unclear risk of bias in most studies.  Many different types of yoga were studied.  In the end however, when yoga was present, even if only for weeks, there were positive and beneficial effects noted in multiple modifiable CV risk factors.